IP269. Intraoperative Cone Beam Computed Tomography Pulmonary Angiography: An Effective Adjunct Imaging Tool for Rapid Diagnosis and Safe Catheter-Directed Thrombolysis

Abstract

Submassive and massive pulmonary embolism (PE) is associated with high mortality, and effective treatment lies within a short window of time. In these instances, rapid diagnosis and treatment are vital for providing fast and efficacious care. We report a novel technique of intraoperative cone beam computed tomography pulmonary angiography (CBCT-PA) for diagnosis and treatment of PE in selected highly morbid cases. Between April 2015 and February 2016, patients who underwent intraoperative CBCT-PA were retrospectively reviewed. In our hybrid operating room equipped with a robotic angiography system (Artis zeego; Siemens Healthcare GmbH, Erlangen, Germany), CBCT-PA images were acquired using a 5-second CBCT protocol (syngo DynaCT; Siemens) after injection of 40 mL of 50% iodinated contrast material at 8 mL/s through a pigtail catheter in the main pulmonary artery. Four patients underwent intraoperative CBCT-PA during the study period. Two of four patients (50%) were hemodynamically unstable in the intensive care unit and deemed unstable for transfer to computed tomography imaging in the radiology suite. These patients were taken directly to the operating room under high suspicion of massive PE and for possible intervention. In one patient, CBCT-PA revealed a large embolus in the left pulmonary artery (Fig 1), prompting an attempt at mechanical thrombectomy. In the other patient, CBCT demonstrated only a small subsegmental embolus in the right lower lobe pulmonary artery (Fig 2), which made PE the unlikely cause for acute decompensation. In the remaining two patients, CBCT imaging was performed for follow-up after placement of thrombolytic catheters the day before. CBCT demonstrated residual clot in subsegmental branches, and thrombolytic catheters were repositioned. Both patients did well after removal of thrombolytic catheters and prescription of systemic anticoagulation. CBCT-PA is an effective adjunct imaging tool for diagnosis of PE in the operating room, especially in hemodynamically unstable patients, for whom transfer to the radiology imaging suite is often unsafe, and during catheter-directed thrombolysis. Until conventional computed tomography imaging becomes routinely available in the operating room, such novel intraoperative imaging options can be a valuable addition to the PE response team algorithm to optimize care in patients with PE.Fig 2Oblique coronal reconstruction of computed tomography image showing small embolus in the left lower lobe pulmonary artery (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT)